131. Key: D                                     

Client Need: Pharmacological and Parenteral Therapies

D. Diabinese is a sulfonamide. a sulfur-based drug, used to treat type 2 diabetes. It would be contraindicated in a patient with an allergy to sulfur. Therefore, the physician should be notified.

A. Aspirin is a non-steroidal anti-inflammatory drug. It is a salicylate and not related to sulfur-based medications.

B. Penicillin is a broad-spectrum antibiotic and is frequently the next choice of drug to treat bacterial infections when the patient is allergic to sulfur.

C. Iodine is a nonmetallic element that aids in the development of the thyroid gland. It is used to treat goiter.

132.Key: B

Client Need : Management of Care

B. If a nurse chooses to stop and give aid at the scene of an emergency.the Good Samaritan Act provides the following guidelines. The nurse should give care that any reasonable, prudent person would consider first aid. Do not do what you don't know. Offer assistance, do not insist. Do not leave the scene until the injured victim leaves or another qualified person lakes over.

A. There arc only a few US states that mandate stopping to give aid at the scene of any emergency.The Good Samaritan Act covers those who choose to give aid.

C. The nurse, like anyone else, is only accountable for first aid as described in the above statement.The nurse should not initiate care if he/she is unsure of the appropriate care.

D. When acting as a "Good Samaritan." the nurse is not expected to perform under the direct orders of a physician.

133. Key: C                                                      

Client Need: Basic Care and Comfort

C. Meat, fish. poultry. eggs and dairy products are foods high in protein. Fruits and vegetables have only a small to scant amount of protein. Therefore. vegetable soup and tossed green salad would be a complex carbohydrate. low-protein meal, and an excellent choice for someone on a protein-restricted diet.

A. A fruit and cheese platter would be high in carbohydrates. protein and fat since cheese is a high-fat,high-protein food.

B. A tuna fish and tomato sandwich would be high in protein and carbohydrates.

D. Meat loaf with rice is also high in protein and carbohydrates.

134. Key: B

Client Need: Coping and Adaptation

B. Crossed arms and legs and turning away from a person are nonverbal behavioral signs that convey an unwillingness to communicate with another. The use of this closed body language is one way the wife conveys that she is distancing herself from a meaningful conversation.

A. The term, incongruence. is applied when nonverbal behavior does not correspond or agree with the verbal message expressed by an individual. Because the question does not provide the verbal message that the wife is communicating along with this nonverbal behavior, the presence of incongruence cannot be determined.

C. The term. blocking, relates to an abnormal thought process that occurs when there is a sudden cessation of thought in the middle of a sentence. The person is unable to continue the train of thought or introduces a new idea.

D. Cultural posturing refers to nonverbal behavior, gestures. and spatial determinants that are customary for a given culture. The meaning of nonverbal communication must be understood from a cultural perspective to accurately interpret the meaning of verbal communication. The family's cultural background is not provided in the question.

135. Key:C                                              

Client Need: Psychosocial Adaptation

C. Delusions are fixed, false beliefs that result from misperceived cognitive stimuli but have meaning to a person expressing them. The nurse needs to attempt to see the world as It appears through the eyes of a patient in order to better understand his delusional experience. It is important for the nurse to understand the patient's feelings and the meaning of the delusion.

A. A logical explanation about the nature of a delusion will not alter the paranoid patient's sense of reality. Explaining the nature of a delusion can increase the patient's level of anxiety that could in turn lead to further delusional thinking.

B. The nurse should not focus on the delusion or get drawn into a conversation regarding it's content.Encouraging the patient to talk about the delusion can reinforce the false beliefs.

D. Delusional thinking is defensive and is a response to anxiety. Pointing out that the patient's beliefs are false will increase anxiety further and prevent the patient from disclosing his thoughts and feelings.